| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
| ||||||||||||||
| ||||||||||||||
|
|
|
|
||||||||||||
|
||||||||||||||
Department of Anesthesiology, Doernbecher Children’s Hospital, Oregon Health Sciences University, Portland, Oregon
Address correspondence and reprint requests to Berklee Robins, MD, Assistant Professor, Department of Anesthesiology, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, UHS-2, Portland, Oregon 97201-3098. Address e-mail to robinsb @ohsu.edu.
 |
Introduction |
|---|
 Top Introduction Case ReportDiscussionReferences |
|---|
|
Case Report |
|---|
|
TopIntroductionCase ReportDiscussionReferences |
|---|
A baclofen trial via a percutaneous intrathecal catheter had previously resulted in marked improvement in his spasticity, greatly facilitating his care and comfort. He was therefore scheduled for placement of a permanent indwelling baclofen delivery system. The patient subsequently underwent general endotracheal anesthesia with isoflurane, nitrous oxide, cisatracurium, and fentanyl (50 mcg) for placement of an indwelling intrathecal catheter (Medtronic InDura®1P, Model 8709; Medtronic, Minneapolis, MN) and infusion pump. Multiple passes at multiple levels were made with the 15-gauge spinal introducer needle, each resulting in grossly bloody CSF. The catheter (4F) was eventually inserted through the needle at the L3-4 interspace, and freely drained minimally blood-tinged CSF. The remainder of the operation was uncomplicated. Total IV fluids were 30 mL/kg, and bupivacaine 0.25% (8 mL) was infiltrated in the wounds. Morphine and ketorolac were administered in the recovery room for apparent discomfort, with improvement.
On the ward, the patient’s initial recovery was uneventful. Postoperative analgesia with IV fentanyl was maintained for the first 48 h, then changed to oral hydrocodone. However, he was unable to tolerate solids or liquids without vomiting and retching. IV fentanyl was restarted on postoperative day 4. Sequential treatment with droperidol, ondansetron, and ranitidine were unsuccessful. IV hydration was maintained. On the sixth postoperative day the pediatric neurosurgeon consulted the pediatric anesthesiology service to evaluate the patient for a possible persistent CSF leak as the cause of the vomiting.
On examination, the child was fussy and in mild distress. He was not smiling or interacting as he had been preoperatively. The father stated his son was uncomfortable when moved or repositioned, and he described mild photophobia. Vital signs were stable and the patient was afebrile. There was no nuchal rigidity or nystagmus. Both lumbar and abdominal incisions were clean, without erythema or discharge. The patient appeared uncomfortable with any change of position, but when raised from supine to upright, he showed no exacerbation of discomfort.
Despite the lack of positional symptoms, a persistent CSF leak was considered likely given the history of multiple dural punctures with a large bore needle. Given the lack of response to medical therapy, an EBP was deemed to be a reasonable treatment.
Under monitored propofol sedation, the sacral area was sterilely prepared and draped and a 1-1/4-in. 20-gauge IV catheter placed via the sacral hiatus into the caudal epidural space. A syringe of the patient’s blood was then sterilely withdrawn from an arm and injected via the catheter into the caudal space until resistance was felt (total volume of 8 mL). Recovery from propofol sedation was prompt and uneventful.
The patient was able to tolerate oral liquids and solids shortly after the procedure. He was discharged home the next morning. He remained symptom-free at home the next day, as well as at long-term follow-up 1 yr later.
|
Discussion |
|---|
|
TopIntroductionCase ReportDiscussionReferences |
|---|
The use of an EBP in a child was first described for treatment of PDPH in a 12-year-old after myelography (6). The youngest patient treated for PDPH with an EBP was 7 years old (7). EBP has also been used to treat an asymptomatic CSF leak after subarachnoid drain removal in two 6-year-olds (8).
Our patient had a symptomatic CSF leak, but because of his developmental handicap, was unable to communicate, and it could not be determined if he had a PDPH. Similarly, we could not ascertain whether he had other symptoms classically attributed to persistent CSF leak, such as diplopia or tinnitus. His primary presentation was persistent vomiting refractory to medical management. His parents were unsure of the exact cause of his distress, but were convinced that their son was in discomfort. They were increasingly frustrated by the duration of symptoms.
Although not without risks, EBP seemed like a reasonable treatment option. Complications of EBP include backache, radicular pain, and/or transient bradycardia, as well as treatment failure. Meningitis secondary to either preexisting bacteremia or nonsterile technique are the most feared complications and would require removal of the pump if it were to occur in this setting. Because the patient was afebrile, without nuchal rigidity or increased white blood cell count, and the wounds appeared clean, there was no clinical evidence of underlying infection that would be a contraindication to EBP.
Our approach to the epidural space via the caudal route was dictated by the presence of an indwelling catheter and a fresh surgical wound. A lumbar EBP could have resulted in wound dehiscence or trauma to the underlying catheter. Puncture of the pump delivery system would have been catastrophic, necessitating a second operation and surgical replacement. Fortunately, our patient had favorable anatomy for a caudal EBP. This approach is infrequently reported. Caudal EBP has previously been described (9) in a 4-year-old boy with leukemia and subarachnoid-cutaneous fistula from repeated lumbar punctures for chemotherapy. That patient, however, had no symptoms other than drainage of CSF. Caudal blood patch for PDPH has also been described in a postpartum adult in whom the lumbar space could not be identified (10). Our patient received prompt relief of symptoms after his caudal EBP, strongly suggesting that persistent CSF leak was responsible for his complaints. At long-term follow-up, he remained free of eating difficulties, and enjoyed marked improvement in his spasticity.
Persistent leakage of CSF should be considered in the differential diagnosis of postoperative nausea and vomiting in patients after procedures in which the dural sac is pierced. Treatment with an EBP, if not contraindicated, may lead to resolution of the symptoms. The caudal approach to the epidural space may be the easiest, fastest and safest to perform in selected pediatric patients.
|
References |
|---|
|
TopIntroductionCase ReportDiscussionReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  J. C. Sanders, R. Gandhoke, and M. Moro Lumbar Epidural Blood Patch to Treat a Large, Symptomatic Postsurgical Cerebrospinal Fluid Leak of 5 Weeks Duration in a 3-Year-Old Anesth. Analg., March 1, 2004; 98(3): 629 - 631. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
